Healthcare Provider Details

I. General information

NPI: 1710484449
Provider Name (Legal Business Name): ANTIONETTE DIANE FEFEE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18004 OAKLEY AVE
LANSING IL
60438-1891
US

IV. Provider business mailing address

18004 OAKLEY AVE
LANSING IL
60438-1891
US

V. Phone/Fax

Practice location:
  • Phone: 312-749-4360
  • Fax: 708-895-2830
Mailing address:
  • Phone: 312-749-4360
  • Fax: 708-895-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008472
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: